INTERNATIONAL PATIENT SAFETY GOALS (IPSG)

INTRODUCTION:
The IPSG are a set of critical standards established by the Joint Commission International (JCI) improve
patient safety across healthcare settings worldwide. These goals provide a framework for healthcare
organizations to minimize risks, reduce errors and prevent patient harm.
There are 7 IPSGs established by JCI. Which are as follow:

1. Identify patient correctly

2. Improve effective communication
3. Improve safety of high alert medication
4. Ensure safe surgery
5. Reduce the risk of healthcare associated infection
6. Reduce the risk of patient harm resulting from falls
7. Reduce the harm associated with clinical alarm systems

1. IDENTIFY PATIENT CORRECTLY

Patient misidentification is a major source of medical errors and can lead to potentially dangerous
outcomes such as administering the wrong treatment, performing surgery on the wrong patient or causing
delays in urgent care.
The IPSG 1: Identify Patient Correctly is a fundamental goal that aims to minimize the risks.
OBJECTIVE: The primary aim is to ensure that each patient is accurately and consistently identified at
every point of care to prevent miscommunication, wrong treatments and procedural errors.
IMPLEMENTATION STRATEGIES:
A multilayered approach is recommended for ensuring patient identification accuracy.
1) TWO-IDENTIFIER POLICY: -
This considered as gold standard for accurate patient identification.
Common identifiers:
a) Full name of the patient
b) Date of birth
c) Medical record number (MRN)
d) Unique patient identifier (e.g. national health ID or hospital specific ID)
e) Barcoded wristband
f) Patient’s address or photograph
g) Room number or bed number

2) SPECIMEN LABELING AT BEDSIDE: -

Proper specimen labeling is crucial as even a small mistake can lead to diagnostic errors,
inappropriate treatment plans or delayed care.
a) Immediate labeling:
Specimens like blood, urine or tissue samples should be labeled immediately after collection.
b) Clear and legible labels
3) BARCODING SYSTEMS: -
It’s an advanced method by which human errors controlled.
a) How barcoding working:
Before administering medication, the healthcare professional scans both the patient’s wristband
and the relevant medication or sample.
b) Integration with electronic health records (EHRs):
Barcoding systems are often integrated with EHRs, provide real-time access to patient data.

4) PATIENT INVOLVEMENT: -
When feasible, the patients should be asked to confirm their name, date of birth and procedure before
any medical intervention.
Special considerations: for unconscious, impaired, mentally ill patients and infants use photographs.

5) HIGH-RISK SCENARIOS: -
Certain situations have higher risk for misidentification and require extra precautions.
a) Emergency situations:
Patients may be unconscious or unable to communicate then temporary identifiers or trauma
numbers used for identification.
b) Transferring patients between departments:
Verify patient’s identity using two-identifier policy.
c) Newborn and pediatric patients:
Using wristbands with barcode or handprints and footprints for identification.

TECHNOLOGY AND INNOVATIONS IN PATIENT IDENTIFICATION:

i. Radio Frequency Identification (RFID)- wristbands and tags.
ii. Biometric identification- fingerprint scanning, iris and facial recognition.
iii. Patient photo identification in EHRs
OUTCOME:
i. Fewer wrong-patient procedures
ii. Reduced medication errors
iii. Improved diagnostic accuracy
iv. Patient safety culture
CHALLENGES AND CONSIDERATIONS:
i. Complacency
ii. Over-reliance on technology

2. IMPROVE EFFECTIVE COMMUNICATION

IPSG 2 focuses on improving the clarity, timeliness and accuracy of communication to enhance patient
care and avoid errors.
OBJECTIVE: To ensure that communication among healthcare professionals, especially regarding
critical patient information, is clear, accurate and timely, thus reducing errors and improving patient
outcomes.
IMPLEMENTATION STRATEGIES:
1) IMPLEMENT STANDARDIZED COMMUNICATION PROTOCOLS: -
a) SBAR protocol (Situation, Background, Assessment, Recommendation)
b) I-PASS method (Illness severity, Patient summary, Action list, Situation awareness and
contingency planning, and Synthesis by receiver)

2) ENSURE VERBAL OR TELEPHONE ORDERS ARE READ BACK FOR ACCURACY: -

a) Read-back process
b) Standardized verbal order policy
3) TIMELY COMMUNICATION OF CRITICAL TEST RESULTS OR URGENT REPORTS: -
a) Establish protocols for critical results reporting (e.g. life-threatening laboratory values, imaging
findings for immediate attention)
b) Use electronic alerts (e-mail, message, call)
c) Tracking and follow-up system (EHR alerts)

4) IMPROVE INTERDISCIPLINARY COMMUNICATION: -

Communication between doctors, nurses, pharmacists and allied healthcare professionals.
a) Interdisciplinary team meetings
b) Daily briefings or safety huddles

5) TRANING AND EDUCATION ON COMMUNICATION SKILLS: -

a) Communication skills training
b) Cultural competence in communication

6) USE OF TECHNOLOGY TO ENHANCE COMMUNICATION: -

a) Electronic Health Records (EHR)
b) Secure messaging systems
c) Telemedicine and remote communication tools
OUTCOMES:
i. Fewer misunderstanding and errors
ii. Timely interventions and treatments
iii. Improved patient outcomes
iv. Enhanced team collaboration
v. Reduced stress and improved job satisfaction
CHALLENGES AND CONSIDERATIONS:
i. Time constraints
ii. Technology dependence
iii. Resistance to change

3. IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS

IPSG 3 is to implement strategies that reduce the risks associated with the use of high alert medications
like insulin, anticoagulants, opioids, and chemotherapy drugs.
OBJECTIVE: To protect patients from the heightened risks associated with high alert medications by
implementing robust systems and protocols for their safe prescribing, dispensing, administration and
monitoring.
IMPLEMENTATION STRATEGIES:
1) SEGREGATION OF HIGH ALERT MEDICATIONS: -
a) Separate storage areas
b) Clear labeling

2) STANDARDIZED PROTOCOLS FOR PRESCRIBING, DISPENSING AND ADMINISTERING

HIGH ALERT MEDICATIONS: -
a) Double check systems
b) Independent verification
c) Use of technology (Computerized Provider Order Entry- CPOE)
d) Infusion pumps (smart infusion pumps with Dose Error Reduction Systems- DERS)

3) CLEAR LABELING OF HIGH ALERT MEDICATIONS: -

a) Color-coded labels
b) Standardized label content
c) Unit dose packaging

4) PATIENT EDUCATION: -
a) Explain proper usage
b) Highlight potential side effects
c) Provide written materials

5) REGULAR MONITORING AND REPORTING: -

a) Monitoring blood levels
b) Incident reporting
OUTCOME:
i. Reduction in medication-related errors
ii. Fewer adverse drug events (ADEs)
iii. Enhanced patient safety for vulnerable population
iv. Improved patient trust and satisfaction
v. Compliance with international safety standards
CHALLENGES AND CONSIDERATIONS:
i. Time constraints
ii. Training and education
iii. Technology limitations

4. ENSURE SAFE SURGERY

IPSG 4 dedicated to improving the safety of surgical procedures by ensuring adherence to strict
guidelines and fostering collaboration among the surgical team.
OBJECTIVE: To prevent surgical errors by ensuring that safety protocols are rigorously followed,
promoting clear communication among the surgical team, and ensuring that the correct procedure is
performed on the right patient and site.
IMPLEMENTATION STRATEGIES:
1) ADOPT THE WHO SURGICAL SAFETY CHECKLIST: -
a) Preoperative verification (Sign-in)
b) Site marking
c) Timeout (before skin incision)
d) Sign-out (before the patient leaves the operating room)

2) TEAM BRIEFING AND DEBRIEFINGS: -

a) Preoperative briefings
b) Postoperative briefings
3) CLEAR COMMUNICATION AMONG TEAM MEMBERS: -
a) Role clarity
b) Encouraging open communication
c) Use of closed-loop communication

4) CHECKLIST FOR EQUIPMENT AND INSTRUMENT VERIFICATION: -

a) Availability of necessary equipment
b) Sterilization of instruments
c) Counting instruments and materials

5) TRAINING AND EDUCATION ON SURGICAL SAFETY: -

a) Simulation trainings
b) Continuing education on safety protocols
OUTCOME:
i. Reduced wrong-site, wrong-procedure and wrong-patient surgeries
ii. Enhanced teamwork and communication
iii. Improved patient outcomes
iv. Fewer retained surgical items
v. Improved compliance with safety protocols
vi. Better overall patient satisfaction
CHALLENGES AND CONSIDERATIONS:
i. Time constraints and resistance
ii. Compliance consistency
iii. Technological dependence

5. REDUCE THE RISK OF HEALTHCARE ASSOCIATED INFECTIONS (HAIs)

IPSG 5 focuses on minimizing the occurrence of HAIs through rigorous adherence to infection prevention
practices.
OBJECTIVE: To significantly reduce the incidence of HAIs by implementing standardized infection
control protocols, ensuring proper use of personal protective equipment (PPE), improving hand hygiene
compliance and fostering a culture of continuous education and vigilance in healthcare facilities.
IMPLEMENTATION STRATEGIES:
1) STRICT ADHERENCE TO HAND HYGIENE PROTOCOLS: -
a) Five moments of hand hygiene by WHO
i) Before touching a patient
ii) Before a clean or septic procedure
iii) After body fluid exposure risk
iv) After touching a patient
v) After touching patient surroundings
b) Promoting compliance
c) Hand hygiene culture

2) USE OF PERSONAL PROTECTIVE EQUIPMENTS (PPE): -

a) Standard precautions (PPE kit, gloves, gowns, caps, masks, goggles or face shields)
b) Appropriate donning and doffing of PPE (don-put on, doff-pit off)
c) PPE availability and accessibility

3) IMPLEMENT CARE BUNDLES FOR DEVICE-ASSOCIATED INFECTIONS: -

a) Central line associated bloodstream infections (CLABSIs)
b) Catheter associated urinary tract infections (CAUTIs)
c) Ventilator associated pneumonia (VAP)
d) Surgical site infection (SSIs)

4) REGULAR STAFF TRAINING ON INFECTION PREVENTION: -

a) Staff education and training programs:
i) Hand hygiene protocols
ii) Proper use of PPE
iii) Techniques for inserting and maintaining invasive devices
iv) Cleaning and disinfecting protocols
v) Recognizing and isolating patients of infectious diseases
b) Simulation based training

5) CONTINUOUS MONITORING OF INFECTION RATES AND FEEDBACK: -

a) Surveillance systems
b) Data-driven interventions
c) Feedback to staff
OUTCOME:
i. Reduced incidence of HAIs
ii. Improved patient outcomes
iii. Lower healthcare costs
iv. Enhanced staff knowledge and accountability
v. Improved hospital reputation and accreditation
CHALLENGES AND CONSIDERATIONS:
i. Resource limitations
ii. Staff compliance and fatigue
iii. Emerging infections and antimicrobial resistance
6. REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALL
IPSG 6 focuses on implementing fall prevention strategies to safeguard patients, especially those at higher
risk.
OBJECTIVE: To prevent patient falls and minimize the associated injuries by implementing
comprehensive fall-risk assessments, environmental modifications, patient and caregiver education, and
the use of assistive devices in healthcare settings.
IMPLEMENTATION STRATEGIES:
1) CONDUCT ROUTINE FALL-RISK ASSESSMENTS: -
a) Fall-risk assessment tools: tools such as Morse Fall Scale or Hendrich 2nd Fall Risk Model assess
risk factors like history of falls, impaired gait or balance, use of medications that affect cognition
or mobility and presence of diseases like orthostatic hypotension and cognitive impairment.
b) Key risk factors to assess: age (elderly patients or children), medications (sedatives,
antidepressants, antihypertensives), mobility limitations (use of cane or walker, muscle weakness,
unsteady gait), cognitive impairment (dementia or confusion), history of previous falls.
c) Frequency of assessment: at admission, periodic or after any reported fall.

2) IMPLEMENT FALL PREVENTION STATEGIES: -

a) Non-slip footwear
b) Mobility aids (canes, walkers or siderails)
c) Bed alarms and low beds
d) Use of bedside commodes and raised toilet seats
e) Call bell accessibility

3) PATIENT AND CAREGIVER EDUCATION: -

a) Patient education (education about fall preventing aids or use assistive devices)
b) Caregiver involvement (encourage patients to use mobility aids)

4) ENVIRONMENTAL MODIFICATIONS: -
a) Well-lit areas (proper lighting or visibility)
b) Clear pathways
c) Furniture arrangement
d) Secure medical equipment

5) REGULAR STAFF TRAINING ON FALL PREVENTION: -

a) Staff education
b) Simulation based training

6) POST-FALL PROTOCOLS AND CONTINUOUS MONITORING: -

a) Post-fall assessment
b) Incident reporting and investigation
c) Root cause analysis (RCA)

7) MULTIDISCIPLINARY APPROACH
a) Physical therapy
b) Occupational therapy
c) Pharmacist involvement
OUTCOME:
i. Reduced rates of patients fall
ii. Fewer fall related injuries
iii. Improved patient outcomes and quality of care
iv. Lower healthcare costs
v. Increased staff awareness and accountability
CHALLENGES AND CONSIDERATIONS:
i. Patient non-compliance
ii. Understanding and workload
iii. Environmental constraints

7. REDUCED HARM ASSOCIATED WITH CLINICAL ALARM SYSTEMS

IPSG 7 focuses on reducing the risk of alarm fatigue by improving management practices and ensuring a
safer, more effective clinical environment.
OBJECTIVE: To address the risk posed by alarm fatigue by customizing alarm settings, developing
protocols to prioritize alarms, providing staff training and leveraging technology to improve the
significance and clarity of alerts
IMPLEMENTATION STRATEGIES:
1) COSTOMIZE ALARM SETTING BASED ON PATIENT CONDITIONS: -
a) Tailoring alarm parameters
b) Reduce falls alarms
c) Alarm delays

2) ESTABLISH ALARM RESPONSE PROTICOL: -

a) Alarm prioritization (high and low priority alarms)
b) Alarm delegation
c) Escalation procedures
d) Document responses

3) TRAIN STAFF TO RECOGNIZE AND PRIOTIZE ALARMS: -

a) Comprehensive alarm training
b) Simulation based training
c) Regular refresher courses

4) INVEST IN SMART ALARM TECHNOLOGY: -

a) Integration of data
b) Predictive analysis
c) Alarm customization software
d) Integration with electronic health records (EHRs)

5) CONTINUOUS MONITORING AND REVIEW OF ALARM SYSTEMS: -

a) Data collection on alarm frequency
b) Quality improvement initiatives
c) Adjusting protocols based on based
6) INVOLVE A MULTIDISCIPLINARY TEAM IN ALARM MANAGEMENT: -
a) Involve nursing leadership
b) Collaborative with biomedical engineers
c) Pharmacist involvement
d) Patient and family education
OUTCOME:
i. Reduction in alarm fatigue
ii. Improved response to critical alarms
iii. Enhanced patient safety
iv. More efficient clinical environment
v. Increased staff satisfaction and retention
vi. Better use of technology
CHALLENGES AND CONSIDERATION:
i. Resource limitations
ii. Staff compliance
iii. Technology malfunctions